Tiffany M.

Osborn, MD
University of Virginia
ACEP Chair Critical Care
Section
ACEP Representative
Surviving Sepsis Campaign
 Purpose for Existence?

Today Future
1,800,000 600,000
Severe Sepsis Cases

Total US Population/1,000
1,600,000 US Population
500,000
1,400,000

>750,000
Sepsis Cases
1,200,000 400,000

cases of severe 1,000,000

sepsis/year 800,000
300,000

in the US* 600,000 200,000

400,000 Incidence projected to

100,000
200,000 increase by 1.5% per year

2001 2025 2050

Year

Angus DC. Crit Care Med. 2001;29(7):1303-1310.

 Comparison With
Other Major Diseases
Incidence of Severe Sepsis Mortality of Severe Sepsis
Cases/100,000

AIDS* Colon Breast CHF Severe AIDS* Breast AMI Severe

Cancer Sepsis Cancer Sepsis

National Center for Health Statistics, 2001. American Cancer Society, 2001. *American Heart Association.
2000. Angus DC et al. Crit Care Med. 2001;29(7):1303-1310.
;29(7):1303-1310
 Comparable Global
Epidemiology
95 cases per 100,000
2 week surveillance
206 French ICUs
95 cases per 100,000
3 month survey
23 Australian/New
Zealand ICUs
51 cases per 100,000
England, Wales and
Northern Ireland.
 Emergency Department Critical
Care Volume Increases
102 million National ED visits in 1999
17% (17.5 million) immediately life threatening1
57 California Emergency Departments (1990-1999)2
50% (387,616) Severe Sepsis Cases Initially Present ED

P < 0.001 for all groups

1. National Center for Health Statistics;

2001
2. Ann Emerg Med 2002;39:389-96
3. Curr Opin Crit Care Dec.2002
 Surviving Sepsis Campaign
A global program to:

Reduce mortality rates

Improve standards of care
Secure adequate funding
 Surviving Sepsis
Phase 1 Barcelona declaration
Phase 2 Evidence based guidelines
Phase 3 Implementation and education
 Surviving Sepsis
Phase 1 Barcelona declaration
Phase 2 Evidence based guidelines
Phase 3 Implementation and education
Sponsoring Organizations
American Association of European Society of
Critical-Care Nurses Clinical Microbiology and
Infectious Diseases
American College of Chest
Physicians European Society of
Intensive Care Medicine
American College of European Respiratory
Emergency Physicians Society
American Thoracic German Sepsis Society
Society Indian Society of Critical
Australian and New Care Medicine
Zealand Intensive Care International Sepsis Forum
Society Society of Critical Care
Medicine
Episepsis Surgical Infection Society
 Surviving Sepsis
Phase 1 Barcelona declaration
Phase 2 Evidence based guidelines
Phase 3 Implementation and education
Clinical Inertia: Tales from
the Past
National Registry MI 2
84,663 MI patients
eligible for reperfusion
24% got NO form of
reperfusion
10 years after therapy
shown to save lives
1 of 4 not treated
10,000 lives lost/year
Estimated 100,000 lives
lost due to failure to treat
Barron, HV. Circulation. 1998;97:1150-1156.
 Clinical Inertia: Low Levels of
Compliance at Research Centers

Cross-sectional analysis of
25,886 patients enrolled in GUSTO-1
659 hospitals, 22 SAVE sites
SAVE: Survival and
Ventricular Enlargement, ACE
(angiotensin-converting enzyme)
benefits post-MI patients with LV
dysfunction

Majumdar SR, et al. Am J Med 2002;113:140-5

 Clinical Inertia: Low Levels of
Compliance at Research Centers

If those who generated the evidence

are slow to translate it into practice, it
is unlikely that passive forms of
dissemination can improve the quality
of care. To accelerate adoption of new
evidence, we need to understand
factors other than knowledge and
awareness that influence practice.

Majumdar SR, et al. Am J Med 2002;113:140-5

 Phase 3: Collaboration for
Implementation
Partner with Institute for
Healthcare Improvement
(IHI) www.IHI.org
Non-profit organization
Healthcare improvement
Quality based initiatives
Set Quality Benchmarks
JCAHO
Medicare
Medicaid
3rd party payers
 What is a Bundle?

Specifically selected
care elements
From evidence based
guidelines
Implemented together
provide improved
outcomes compared to
individual elements
alone
 SSC Steering Committee:
Global Consensus

13 September 2004
Catania, Sicily
Steering
Committee Met
6 hour bundle
formed
24 hour bundle
formed
Gaining Consensus:
Finding Nemo
6 Hour Resuscitation Bundle

Early Identification
Early Antibiotics and
Cultures
Early Goal Directed
Therapy
 6 - hour Severe Sepsis/
Septic Shock Bundle
Early Detection:
Obtain serum lactate level.
Early Blood Cx/Antibiotics:
within 3 hours of
presentation.
Early EGDT:
Hypotension (SBP < 90, MAP
< 65) or lactate > 4 mmol/L:
initial fluid bolus 20-40 ml of
crystalloid (or colloid equivalent)
per kg of body weight.
Vasopressors:
Hypotension not
responding to fluid
Titrate to MAP > 65
mmHg.
Septic shock or lactate > 4
mmol/L:
CVP and ScvO2 measured.
CVP maintained >8 mmHg.
MAP maintain > 65 mmHg.
ScvO2<70%with CVP > 8
mmHg, MAP > 65 mmHg:
PRBCs if hematocrit < 30%.
Inotropes.
 Rhode Island Hospital EGDT Data

Time from Entering ED Time from Entering ED

to Receiving Antibiotics to Catheter Insertion Time from Entering ED
Reduced by 42%
to Transfer to MICU
Reduced by 60%
Reduced by 51%
 24 - hour Severe Sepsis
and Septic Shock Bundle
Glucose control:
maintained on average <150 mg/dL (8.3 mmol/L)
Drotrecogin alfa (activated):
administered in accordance with hospital guidelines
Steroids:
for septic shock requiring continued use of vasopressors
for equal to or greater than 6 hours.
Lung protective strategy:
Maintain plateau pressures < 30 cm H2O for
mechanically ventilated patients
Phase 3: Collaboration
for Implementation
Partner with Institute for
Healthcare Improvement
(IHI)
Develop sepsis
management change
bundles
Provide tools and
systems for
implementation and
improvement
Enhanced quality
Improved mechanisms
 SSC Educational Tool Kit

Implementation Sepsis
Bundles
Web-based and CD rom
IHI Website (IHI.org)
Tool Kit
Educational material
Process for developing
Change teams
Data collection tools and
descriptions (database)
Taylor: Culture Specific
 The Future: ED and ICU
Interface
Collaboration:
Emergency Medicine
and Critical Care
Defining patient care
globally
Setting standards for
ED/ICU collaborations
Establishing new format
to change clinical
practice and improve
outcomes
Providing tools
JCAHO, Medicare
THANK YOU!!